Shape memory filament for suture management

ABSTRACT

A member of a rigid flexible elastic material, the member including a body portion and an aperture portion with the member adapted for delivery through an axial longitudinal channel of a percutaneous delivery subsystem, the aperture portion including an expanded mode having a lateral dimension greater than an inner diameter of the channel when the aperture portion extends outside the channel and a collapsed mode wherein the lateral dimension is not greater than the inner diameter of the channel when the aperture portion is within the channel, the channel including a first axial opening and a second axial opening with the aperture portion transitioning from the expanded mode to the collapsed mode when inserted into the openings and the aperture transitioning from the collapsed mode to the expanded mode when exiting from the openings.

CROSS REFERENCE TO RELATED APPLICATIONS

This Application is a Division of application Ser. No. 11/309,829 filedon Oct. 5, 2006.

BACKGROUND OF THE INVENTION

The invention relates generally to surgical suture management and morespecifically to a percutaneous suture management system and method, morespecifically for suture fixation of tissue, through procedures such asfor example open and arthroscopic surgeries.

Arthroscopic suturing techniques and instruments have been developed inorder to facilitate the suturing of tissue during arthroscopic surgicalprocedures. In arthroscopic surgery, access to a surgical work sitewithin a patient's body is normally provided through one or more portalsformed directly in the patient's body or through one or more cannulasinserted into the body of a patient through small incisions. A chosensurgical procedure is carried out by a surgeon through the use ofelongated instruments inserted through these cannulas and it oftenbecomes necessary to suture selected tissue at the surgical work site.

Since the work site is only accessible through a small portal or cannulaand since it is very difficult to tie sutures within the body, variousdevices and techniques have been developed to enable the surgeon tomanipulate sutures arthroscopically. For example, some procedures enablethe surgeon to pass suture material through selected tissue, form asurgical knot extracorporeally and then move the knot with a knot pusherthrough the portal or cannula into position adjacent the desired tissueto be sutured. Some cannula instruments used to pass the sutureincorporate a hollow needle provided with some structure, often a wireloop, to guide the suture through the tissue pierced by the needle, withthe needle extended through a cannula. It is known to use a non-metallicsuture shuttle having loops on opposite ends for passing through thebore of a roller type suture passing device. In some cases, each loop ofthe suture shuttle includes a short leader portion in the form of asingle strand monofilament for threading the suture shuttle through thebore of the elongated instrument. In other cases, the short leaderportion is eliminated, and the surgeon must squeeze the leading looptogether to insert the shuttle into the bore of the elongatedinstrument.

These instruments are typically available for use exclusively throughthe cannula and because cannula placement locations are limited, theability of a surgeon to place and tie each suture at optimum locationsis constrained, both by placement of the cannula as well as limitationsof working exclusively through the cannula when placing and tying eachsuture. For example, when working through a cannula or similar portal, asurgeon may have about forty degrees of freedom from a central axis ofthe portal in which to locate and place sutures. When it is necessary ordesirable to locate sutures outside of this limit, then the surgeon mustweigh the disadvantages of adding another portal/cannula in anappropriate location against the advantages of positioning the suture atthe optimum location. Sometimes such a suture is not used or it islocated sub-optimally because the disadvantages predominate. Ininstances in which it would be desirable to position or distributesutures through a wide range of angles, it becomes impractical to usearthroscopic techniques due to the relatively large number ofportals/cannulas that are required.

A shape memory alloy (SMA) (also known as memory metal or smart wire) isa metal that remembers its geometry. After it is deformed, it regainsits original geometry by itself during heating (one-way effect) or, athigher ambient temperatures, simply during unloading(pseudo-elasticity). Main types of SMA include copper-zinc-aluminum,copper-aluminum-nickel, and nickel-titanium (NiTi) alloys. NiTi alloysare generally more expensive and possess superior mechanical propertieswhen compared to copper-based SMAs. The nickel-titanium alloys werefirst developed in 1962-1963 by the Naval Ordnance Laboratory andcommercialized under the trade name Nitinol (an acronym for NickelTitanium Naval Ordnance Laboratories). Metal alloys are not the onlythermally responsive materials, as shape memory polymers have also beendeveloped, having become commercially available in the late 1990's.There is another type of SMA called ferromagnetic shape memory alloys(FSMA), that change shape under strong magnetic fields. These materialsare of particular interest as the magnetic response tends to be quickerand more efficient than temperature-induced responses. Shape memoryalloys are able to show an obviously elastic deformation behavior whichis called Mechanical Shape Memory Effect or Superelasticity. Thisdeformation can be as high as 20× of the elastic strain of steel.

In surgery, percutaneous pertains to any medical procedure where accessto inner organs or other tissue is done via a puncture or a piercing ofthe skin, rather than by using an “open” approach where inner organs ortissue are exposed (typically with the use of a scalpel or blade to makean incision) or through a cannula or other portal.

What is needed is an apparatus, system, and method for enabling asurgeon to quickly and accurately position a suture at any desiredlocation and optionally along a preferred suture pathway without undueconstraint by cannula or other portal systems.

BRIEF SUMMARY OF THE INVENTION

Disclosed is an apparatus, system, and method for percutaneous suturemanagement system that enables an operator to quickly and accuratelyposition a suture at any desired location and optionally along apreferred suture pathway without constraint by cannula or other portalsystems. The apparatus includes a member of a rigid flexible elasticmaterial, the member including a body portion and an aperture portionwith the member adapted for delivery through an axial longitudinalchannel of a percutaneous delivery subsystem, the aperture portionincluding an expanded mode having a lateral dimension greater than aninner diameter of the channel when the aperture portion extends outsidethe channel and a collapsed mode wherein the lateral dimension is notgreater than the inner diameter of the channel when the aperture portionis within the channel, the channel including a first axial opening and asecond axial opening with the aperture portion transitioning from theexpanded mode to the collapsed mode when inserted into the openings andthe aperture transitioning from the collapsed mode to the expanded modewhen exiting from the openings.

A system includes a percutaneous delivery subsystem including atissue-penetrating member defining an axial longitudinal channel havingan internal longitudinal cross-section with the channel including afirst longitudinal opening and a second longitudinal opening; and amember of a rigid flexible elastic material, the member including a bodyportion and an aperture portion with the member adapted for deliverythrough the axial longitudinal channel, the aperture portion includingan expanded mode having a lateral dimension greater than a greatestwidth of the internal longitudinal cross-section when the apertureportion extends outside the channel and a collapsed mode wherein thelateral dimension is not greater than the greatest width of the channelwhen the aperture portion is within the channel, with the apertureportion transitioning from the expanded mode to the collapsed mode wheninserted into the openings and the aperture transitioning from thecollapsed mode to the expanded mode when exiting from the openings.

A method includes a) installing a suture anchor with an attached suturestrand in a portion of body adjacent a section of tissue to be securedwithin a body; b) piercing percutaneously the tissue with a sharp distalend of a spinal needle having a channel extending from the sharp distalend to a proximal end outside the body; c) inserting a member into anend of the spinal needle, the member including a body portion and anaperture portion with the member adapted for delivery through thechannel, the aperture portion including an expanded mode having alateral dimension greater than an inner diameter of the channel when theaperture portion extends outside the channel and a collapsed modewherein the lateral dimension is not greater than the inner diameter ofthe channel when the aperture portion is within the channel, theaperture portion transitioning from the expanded mode to the collapsedmode when inserted into the ends and the aperture transitioning from thecollapsed mode to the expanded mode when exiting from the ends; d)deploying the aperture portion from the sharp distal end; e) capturingthe suture strand with the aperture portion; and f) passing the capturedsuture strand through the tissue by retracting the aperture portionthrough the tissue. A method for repairing a superior labrum anterior toposterior tear includes a) installing a posterior portal into a shoulderproximate the superior labrum; b) installing a suture anchor at about aforty-five degree angle into a glenohumeral joint of the shoulder, thesuture anchor including at least one suture; c) inserting percutaneouslya needle into the shoulder, the needle adjacent a lateral acromion andpassing through a supraspinutas tendon of the shoulder; d) introducing asuture transport into the glenohumeral joint through a channel of theneedle; e) coupling the suture to the suture transport; and f)extracting the suture transport from the shoulder to extend the suturefrom the anchor outside the shoulder through the supraspinutas tendon.

Embodiments of the present invention for suture transports are simplerand more efficient than conventional systems for not only passing,delivering, and installing sutures but also to define suture pathsthrough multiple tissue types and/or structures in multiple discretesteps or in one successive procedure as determined by the operator.Embodiments may require fewer portals while providing for a greaterangular access area around a portal using small diameter percutaneouspiercers that cause less overall trauma and reductions in local trauma,thus promoting quicker and lower risk recoveries.

Systems of the preferred embodiment also enable new procedures whilesimplifying other procedures as additional uses and applications for thestructures are implemented. For example, one preferred embodimentincludes a single portal SLAP repair.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a suture transport adapted for percutaneous use according toan embodiment of the present invention;

FIG. 2 is a first alternate embodiment of the suture transport shown inFIG. 1;

FIG. 3 is a second alternate embodiment of the suture transport shown inFIG. 1;

FIG. 4 is a third alternate embodiment of the suture transport shown inFIG. 1;

FIG. 5 and FIG. 6 are a sequence of figures illustrating a percutaneousdelivery subsystem piercing a portion of a human body (e.g., a shoulder)to deliver one of the suture transports (e.g., the transport of FIG. 1)described herein;

FIG. 5 illustrates a suture transport shown in FIG. 1 used with apercutaneous delivery subsystem;

FIG. 6 illustrates a suture transport extending outside the channel ofthe spinal needle puncturing the skin portion of a human body, with theaperture of the suture transport shown in the expanded mode;

FIG. 7 through FIG. 10 are a detailed sequence of figures illustratingresults of use of a percutaneous delivery subsystem piercing a portionof a human body (e.g., a shoulder) to deliver one of the suturetransports (e.g., the transport of FIG. 1) described herein;

FIG. 7 illustrates a portion of a shoulder including installation of asuture anchor into a bone of the shoulder near a desired location for arepair of a capsular tissue portion, the suture anchor including foursuture strands;

FIG. 8 illustrates the portion of the shoulder shown in FIG. 7 after apercutaneous delivery system pierces both the skin of the shoulder andthe capsular tissue at an optimum location and delivers a shuttletransport including an aperture portion through the skin and thecapsular tissue;

FIG. 9 illustrates the portion of the shoulder shown in FIG. 7 and FIG.8 after the shuttle transport is withdrawn through the channel ofpercutaneous delivery system while the delivery system remains partiallywithin the shoulder but withdrawn from the capsular tissue;

FIG. 10 illustrates the portion of the shoulder shown in FIG. 7, FIG. 8,and FIG. 9 after the shuttle transport is completely withdrawn backthrough the shoulder with the suture strand extending from an aperturedefined by the exiting percutaneous delivery system shown in FIG. 7,FIG. 8, and FIG. 9;

FIG. 11 is an external view of the portion of a body (e.g., a shoulderportion) after optimum placement of multiple suture strands using one ormore suture transports described herein in cooperation with a firstportal and a second portal as described herein;

FIG. 12 is side view of a shoulder portion;

FIG. 13 through FIG. 17 are a sequence of views illustrating a SLAPrepair using a suture transport according to a preferred embodiment ofthe present invention;

FIG. 13 is a view subsequent to the FIG. 12 view in which a portal isinstalled into the shoulder segment with a suture anchor and attachedsuture strand secured into the shoulder through the portal;

FIG. 14 is a view subsequent to the FIG. 13 view in which a percutaneousdelivery system has pierced through a skin portion and passed into aninterior of the shoulder portion at the desired location while defininga desired suture path through the desired tissue components;

FIG. 15 is a view subsequent to the FIG. 14 view in which a suturetransport is delivered from the distal end of the percutaneous deliverysystem at the desired location;

FIG. 16 is a view subsequent to the FIG. 15 view in which the suturetransport is extracted out of the shoulder portion through the portalwhile the delivery system is retracted;

FIG. 17 is a view subsequent to the FIG. 16 view in which the suturetransport has retracted one of the suture strands through the portal andthrough the suture path defined by the percutaneous delivery system;

FIG. 18 is a side plan view of a first preferred embodiment for anaperture portion of a suture transport; and

FIG. 19 is a side plan view of a second preferred embodiment for anaperture portion of a suture transport.

DETAILED DESCRIPTION OF THE INVENTION

The following description is presented to enable one of ordinary skillin the art to make and use the invention and is provided in the contextof a patent application and its requirements. Various modifications tothe preferred embodiment and the generic principles and featuresdescribed herein will be readily apparent to those skilled in the art.Thus, the present invention is not intended to be limited to theembodiment shown but is to be accorded the widest scope consistent withthe principles and features described herein.

FIG. 1 is a suture transport 100 adapted for percutaneous use accordingto an embodiment of the present invention. Transport 100 includes amember 105 of a rigid flexible elastic material, member 105 including abody portion 110 and an aperture portion 115. Member 105 is adapted fordelivery through an axial longitudinal channel of a percutaneousdelivery subsystem (e.g., an 18 gauge or smaller spinal needle or otherskin-piercing delivery system, or the like), with aperture portion 115including an expanded mode (as shown in FIG. 1) having a lateraldimension (L) greater than an inner diameter of the channel whenaperture portion 115 extends outside the channel. The collapsed mode(shown, for example, in FIG. 5) provides for lateral dimension L to benot greater than the inner diameter of the channel when aperture portion115 is within the channel. The channel includes a first axial opening ata proximal end (closer to the operator of suture transport 100) and asecond axial opening at a distal end (closer to the piercing end andtypically disposed within the body through a puncture in the skin duringuse). Aperture portion 115 includes, in the preferred embodiment, aleader element 120 used to load/guide aperture portion 115 into thechannel. Leader element 120 may be omitted from some implementations,while in other implementations leader element 120 function is providedin a different manner, such as, for example, to help transition apertureportion 115 from the expanded mode to the collapsed mode, and/or, forexample, to help load body member 105 into the channel of thepercutaneous delivery subsystem, such as the spinal needle. TABLE Ibelow provides Nominal outside diameter, nominal inside diameter, andnominal wall thicknesses for the specified needle gauge.

TABLE I Syringe Needle Dimensions Nominal Nominal Nominal Wall Needle ODID Thickness Gauge (inches) (inches) (inches) 17 .0580 .0420 .0080 18.0500 .0330 .0080 19 .0420 .0270 .0075

In the preferred embodiment, body portion 105 is constructed of a singlemonofilament of rigid memory material (e.g., Nitinol™ other memorymaterial including other metals or polymers, and the like) wound toproduce body portion 110, aperture portion 115, and any leader element120. Body portion 105, including aperture portion 115 in the collapsedmode, is constructed so it passes through an 18 gauge spinal/syringeneedle, or smaller diameter needle (larger gauge number). Body portion105 is sufficiently rigid to be able to be pushed/pulled through theneedle channel, and sufficiently elastic that aperture portion 115repeatedly transitions between the expanded mode and the collapsed mode,permitting multiple uses of one suture transport 100. As long as suturetransport 100 is sufficiently rigid and elastic as described above,alternative constructions may be possible. For example, it may not benecessary to use a superelastic material for construction of body 105,as in some cases a precursor alloy may be sufficient. In otherinstances, a multi-stranded structure may be used in someimplementations.

In operation, aperture portion 115 transitions from the expanded mode tothe collapsed mode when inserted into either of the channel openings andaperture portion 115 transitions from the collapsed mode to the expandedmode when exiting from any of the channel openings. Suture transport 100is constructed in such a way that it may be loaded from either end ofthe channel (e.g., the spinal needle) by inserting either body portion110 or aperture portion 115. Many conventional systems include a handleor other structure that prevents such bi-directional, multi-optionloading. Suture transport 100 of FIG. 1 is specifically constructedwithout a handle or other structure permitting it to pass entirelythrough a channel from either end to the other, irrespective of which“end” of suture transport 100 is inserted into which end of the channel.

FIG. 2 is a first alternate embodiment of a suture transport 200. Suturetransport 200 includes a handle 205 coupled to the proximal end of bodymember 105 shown in FIG. 1. While handle 205 inhibits two-way and“either end” loading of suture transport 200 into the percutaneousdelivery system, suture transport 200 is beneficial by addition of thehandle as that may, in some instances, permit easier insertion orretraction through the channel and/or through tissue of the body, suchas for example, enabling easier application of greater axial forces tobody member 105. In other respects, suture transport 200 correspondsclosely to suture transport shown in FIG. 1 in construction, use, andoperation.

FIG. 3 is a second alternate embodiment of a suture transport 300.Suture transport 300 includes a second aperture portion 305 coupled tothe proximal end of body member 105 shown in FIG. 1. Second apertureportion 305 includes a leader element 310 and also includes an expandedmode with lateral dimension L and a collapsed mode for passage throughthe channel of percutaneous delivery system. Suture transport 300permits flexibility in moving sutures or other elements bi-directionally(e.g., it duplicates a sewing motion by eliminating a step, havingaperture portions at both ends). In other respects, suture transport 300corresponds closely to suture transport shown in FIG. 1 in construction,use, and operation.

FIG. 4 is a third alternate embodiment of a suture transport 400.Transport 400 includes a member 405 of a rigid flexible elasticmaterial, member 405 including a first body portion 410, an apertureportion 415, and second body portion 420, aperture portion 415 disposedbetween the body portions. Member 405 is adapted for delivery through anaxial longitudinal channel of a percutaneous delivery subsystem (e.g.,an 18 gauge or smaller spinal needle or other skin-piercing deliverysystem, or the like), with aperture portion 415 including an expandedmode (as shown in FIG. 4) having a lateral dimension (L) greater than aninner diameter of the channel when aperture portion 415 extends outsidethe channel. One advantage of an implementation such as this is that asuture may be passed without coming out of the skin. In other respects,suture transport 400 corresponds closely to suture transport shown inFIG. 1 in construction, use, and operation.

FIG. 5 and FIG. 6 are a sequence of figures illustrating a percutaneousdelivery subsystem 500 piercing a portion of a human body 505 (e.g., ashoulder) to deliver one of the suture transports (e.g., transport 100of FIG. 1) described herein.

FIG. 5 illustrates suture transport 100 shown in FIG. 1 used withsubsystem 500. In this example, subsystem 500 includes an 18 gauge orsmaller diameter spinal needle having a channel 510. Subsystem 500 isused to deliver the distal end within body 505 to the proper location,including definition of a prospective suture path through various tissueelements within body 505. For example, subsystem 500 may additionallypierce internal tendons, ligaments, and other tissue so that when asuture is captured by the aperture portion and the transport is extendedor retracted, the suture also passes through the pierced intermediatetissue elements at the location(s) and in the order defined by subsystem500. Because subsystem 500 may deliver the distal end to practically anylocation, through many different types of tissue from virtually anyangle or orientation, an operator has almost unlimited options whendefining and implementing the optimum suture path and ingress/egresslocation from body 505. As shown (and as described above) apertureportion 115 is in the collapsed mode when within channel 510.

FIG. 6 illustrates suture transport 100 extending outside channel 510with aperture portion 115 transitioned to the expanded mode. In thepreferred embodiment, aperture portion 115 automatically transitionsfrom the collapsed mode shown in FIG. 5 to the expanded mode shown inFIG. 6 when exiting from the distal end of channel 510 because of theconstruction and configuration of the transports as described herein.When the transport includes one of the handleless embodiments describedherein, after delivering aperture portion 115 to the desired locationthrough the optimum path in body 505, subsystem 500 may be withdrawnfrom body 505, leaving transport 100 in place. Thus, a suture need notpass through delivery subsystem 500 when exiting body 505.

FIG. 7 through FIG. 10 are a detailed sequence of figures illustratingresults of use of a percutaneous delivery subsystem piercing a portionof a human body (e.g., a shoulder) to deliver one of the suturetransports (e.g., the transport of FIG. 1) described herein;

FIG. 7 illustrates a portion of a shoulder 700 including installation ofa suture anchor 705 into a bone of the shoulder near a desired locationfor a repair of a capsular tissue portion 710, suture anchor 705including four suture strands 715 _(n). Suture anchor 705 is installedthrough a first portal 720 and a first suture strand 715 ₁ is retrievedthrough a second portal 735. A gripper, forceps, or other arthroscopictool/accessory may be used to retrieve a suture strand 715 _(x) throughsecond portal 725.

FIG. 8 illustrates the portion of shoulder 700 shown in FIG. 7 after apercutaneous delivery system 730 pierces both the skin of shoulder 700and capsular tissue 710 at an optimum location and delivers a shuttletransport 735 including aperture portion 740 through the skin andcapsular tissue 710. Additionally, aperture portion 740 has beenretrieved through second portal 725 in the same or similar manner assuture strand 715 ₁ was retrieved. Suture strand 715 ₁ is threadedthrough aperture portion 740 while aperture 740 extends outside shoulder700 through second portal 725.

FIG. 9 illustrates the portion of shoulder 700 shown in FIG. 7 and FIG.8 after shuttle transport 735 is withdrawn through the channel ofpercutaneous delivery system 730 while system 730 remains partiallywithin shoulder 700 but withdrawn from capsular tissue 710. Thisdemonstrates another feature of the preferred embodiments, namely thatthe distal end of percutaneous delivery system 730 may be progressivelyadvanced or withdrawn to aid in movement of suture transport 735 withinshoulder 700 and the portals and preferred suture installation path(s).For example, depending upon the needs and preferences of the operator,the distal end of percutaneous delivery system 730 may aid in directingsuture transport 735 during its movement. That is, the distal may remainpositioned through capsular tissue 710 as suture transport (along withsuture strand 715 ₁) is withdrawn back into second portal 725 towardsthe exit point of the distal end through capsular tissue 710. Afterpassing suture transport 735 back into shoulder 700 through secondportal 725, the distal end of system 730 may be withdrawn from capsulartissue 710 and then suture transport 735 withdrawn through capsulartissue 710 where the distal end passed through. Withdrawing suturetransport 735 through capsular tissue 710 also pulls suture strand 715 ₁through capsular tissue 710 along the path defined by delivery system730 as suture strand 715 ₁ is threaded through aperture 740. In somecases, it may not be necessary to progressively withdraw system 730 assuture transport 735 advances along the desired path. The embodiments ofthe present invention provide this flexibility.

FIG. 10 illustrates the portion of shoulder 700 shown in FIG. 7, FIG. 8,and FIG. 9 after shuttle transport 735 is completely withdrawn throughshoulder 700 with suture strand 715 ₁ extending from an aperture 1000defined by the exiting percutaneous delivery system 730 shown in FIG. 7,FIG. 8, and FIG. 9. Suture strand 715 ₁ is thus accurately located,positioned, and installed at the appropriate locations in capsulartissue 710 and through aperture 1000.

FIG. 11 is an external view of the portion of a body 1100 (e.g., ashoulder segment) after optimum placement of multiple suture strands1115 _(n) using one or more suture transports described herein incooperation with a first portal 1120 and a second portal 1125 asdescribed herein. FIG. 11 illustrates some of the advantages of thepresent invention including 360° suture strand 1115 placement withminimum use of portals. With the two portals shown, it is noted thatsuture strand 1115 placement is not limited to locations between the twoportals, nor within a narrow angular range. Thus the tissue (tendons,ligaments, other cartilage or tissue or the like) to be stabilized maybe accessed at virtually any location from virtually any direction andany part of the body portion similarly may be pierced from virtually anydirection providing great flexibility in installing one or more suturestrands in the optimum number, locations, and directions.

The following discusses use of preferred embodiments of the suturetransport for demonstrating preparation of a set of sutures for a SLAPprocedure as applied to repairing shoulder instability. The preparationfor this arthroscopic repair of a shoulder begins by installing a sutureanchor (e.g., in a portion of bone), at a point where a portion ofcapsular tissue is desired to be fixed. Initially, some number ofstrands of suture material attached to the suture anchor is passedthrough a first portal with the anchor prior to installation. Eachstrand is passed through the portion of the capsular tissue. Theprocedures of the preferred embodiments may be achieved in differentmodalities—suture strands may be installed in multiple discrete steps(e.g., successive retrieval of the suture strand in two stages—firstthrough the capsular tissue and then second through the skin coveringthe shoulder portion). The embodiments of the present inventionoptionally provides for such multiple stages to be achieved in a singleintegrated step. That is, a percutaneous delivery system pierces theshoulder and the capsular tissue in one step and delivers the distal endof the delivery system proximate the suture anchor, once for each suturestrand. The suture transport is passed through the channel of thedelivery system so that the aperture portion is available to be loadedwith the suture strand in question. The delivery system is retracted,and then the suture transport delivers the suture strand through thecapsular tissue and the shoulder when retracted. Of course, the presentinvention permits use of the two stage when necessary or desirable byfirst locating each suture strand appropriately through the capsulartissue and then, later, retrieving each strand through the shoulder. Thepresent invention provides a great degree of flexibility, not just withlocating and delivering a suture strand, but also in combining orseparating steps of many arthroscopic procedures used for tissuestabilization. Each suture strand is passed through a portion of theskin of a body part, such as for example a shoulder, each suture strandaccurately, independently, and optimally installed with a minimal numberof portals installed. At this point, arthroscopic knots are tied andadvanced in the normal fashion.

The present invention may be used in a number of surgical proceduresinvolved with tissue tying (e.g., arthroscopic and open surgeries), suchas rotator cuff repair or shoulder instability repair among other typesof procedures in which cartilage (tendons, ligaments, and the like) andother tissue are stabilized and secured.

FIG. 12 is side view of a shoulder 1200. At one level, shoulder 1200 isa ball and socket joint. An upper part of a humerus 1205 includes a ballthat fits into a socket portion of a scapula called a glenoid 1210.Shoulder 1200 is made up of three bones: the scapula (shoulder blade),humerus 1205 (upper arm bone) and a clavicle (collarbone) 1215. A partof the scapula that makes up the roof of the shoulder is called anacromion 1220. A rotator cuff is responsible for the motion, stability,and power of humerus 1205.

A joint where acromion 1220 and clavicle 1215 join together is known asan acromioclavicular (AC) joint. There are ligaments that providestability to this joint. The true shoulder joint is called aglenohumeral joint and is formed by humerus (upper arm) 1205 and aglenoid labrum 1225 of the scapula (shoulder blade). The relative sizeof these two structures is analogous to a golf ball (head of thehumerus) on a golf tee (glenoid). This makes the shoulder joint have alarge range of. This large range of motion also contributes to injuries.One type of injury is the SLAP lesion. Labrum 1225 deepens the golf teeto help make the shoulder more stable. A biceps tendon 1230 attaches atthe top of labrum 1225. This is the area of the SLAP lesion. SLAP is anacronym for Superior Labrum Anterior to Posterior. This describes theway the labrum tears.

The following is a description of a preferred embodiment for a novelSLAP repair making use of a suture transport as described herein. Theglenohumeral joint, subacromial space and proposed portals are injectedwith a combination of lidocaine and Marcaine with epinephrine afterattempting to aspirate prior to injecting. A standard posterior portalis opened using a #15 blade taking care to place the incisions in theLanger lines. A blunt obturator is used to enter the shoulder. The 4 mm30 degree arthroscope is placed in the shoulder and an anterior portalis opened using inside-out technique. A thorough diagnostic arthroscopyis performed.

A lateral portal is not necessary for this type of repair. The posteriorportal is used for viewing and the anterior portal is the workingportal. The superior labral tear is identified. The glenoid is cleaneddown to bleeding cortical bone using an arthroscopic elevator, rasp anda motorized shaver. An arthroscopic awl is frequently used to assure agood bleeding surface.

A drill guide is brought in to the glenohumeral joint through theanterior portal, passed medial to the long head of the biceps tendon andplaced on the posterosuperior glenoid at a 45° angle. The drill isplaced and bottomed out on the guide and removed. Without moving theguide, an anchor is placed and tapped into position until the handlebottoms out on the guide. Multiple counterclockwise turns are performedwith the handle to allow the insertor to be removed. The suture ends aresmartly tugged to set the anchor. An 18 gauge spinal needle is broughtinto the shoulder percutaneously adjacent to the lateral acromion. It isseen to enter the shoulder through the supraspinatus tendon. Thetransport is then introduced through the needle until it enters theglenohumeral joint. A grasper is used to capture the transport and it iswithdrawn through the anterior cannula. The needle is then pulled backthrough the skin. The two suture ends are passed through the loop end(aperture portion) of the transport and the transport is removed leavingthe suture exiting through the skin. The suture end closest to thelabrum is pulled back through the anterior cannula using a grasper.

Through a percutaneous Nevaiser portal the spinal needle is seen toenter the shoulder behind the biceps tendon. When the capsule is tightin this area an arthroscopic probe can be used to pull the capsulemedially for better visualization. The spinal needle is directed underthe labrum and seen to exit between the labrum and the glenoid. Thetransport is introduced through the needle and withdrawn through theanterior cannula. The spinal needle is backed out through the skin. Thesuture limb is passed through the loop end and the transport iswithdrawn leaving the suture through the skin. This is the post fortying. The 2 suture limbs are captured and pulled out through theanterior cannula with both limbs passing medial to the biceps tendon.The sutures are tied using a sliding knot followed by half hitches. Theexcess sutures are cut using an arthroscopic knot cutter.

An anterosuperior anchor is then placed. The suture ends are againwithdrawn in a percutaneous manner laterally. The post suture isretrieved through the anterior cannula. The spinal needle is broughtinto the shoulder through the subclavicular region. This is just medialand superior to the anterior cannula. The transport is introduced andbrought out through the anterior cannula and the needle is backed out ofthe skin. The post suture limb is passed. Both suture limbs are capturedand brought out through the anterior cannula. The sutures are tied andcut. The integrity of the repair is assessed.

FIG. 13 through FIG. 17 are a sequence of views illustrating portions ofthe SLAP repair described above using a suture transport according to apreferred embodiment of the present invention.

FIG. 13 is a view subsequent to the FIG. 12 view in which a portal 1300is installed into shoulder 1200 with a suture anchor 1305 and attachedsuture strands 1310 secured into the posterosuperior glenoid 1210 at the45° angle.

FIG. 14 is a view subsequent to the FIG. 13 view in which a percutaneousdelivery system 1400 for a suture transport 1405 has pierced through askin portion 1410 and passed into an interior of the shoulder portionadjacent to the lateral acromion while defining a desired suture paththrough the desired tissue components (for example in this case, fromskin portion 1410 through the supraspinatus tendon).

FIG. 15 is a view subsequent to the FIG. 14 view in which an apertureportion 1500 of suture transport 1405 is delivered from the distal endof percutaneous delivery system 1400 at the desired location (forexample, into the glenohumeral joint).

FIG. 16 is a view subsequent to the FIG. 15 view in which suturetransport 1405 is extracted out of shoulder 1200 through portal 1300while the delivery system is retracted.

FIG. 17 is a view subsequent to the FIG. 16 view in which the suturetransport has retracted one of the suture strands through the portal andthrough the suture path defined by the percutaneous delivery system. Thetwo suture ends were passed through the loop end (aperture portion 1500)of suture transport 1405 and transport 1405 was removed leaving suture1310 ₁ exiting through the skin. The suture end closest to labrum 1225is pulled back through the anterior cannula (portal 1300) using agrasper.

FIG. 18 is a side plan view of a first preferred embodiment for apertureportion 115 of a suture transport described herein. Aperture portion 115is most preferably configured to include a series of hard discrete bends1800 _(i), i=1 to n that complete a closed loop. When n is equal to 6(first embodiment FIG. 18) or n is equal to 8 (second embodiment FIG.19) then a desirable configuration for aperture portion 115 is achievedas further explained below. FIG. 19 is a side plan view of a secondpreferred embodiment for aperture portion 115 of a suture transportincluding an aperture extending portion 1900 inserted between each oftwo pairs of angles of the embodiment shown in FIG. 18 to produce ageneralized elongated hexagon shape. In the various embodiments of thepresent invention, n may vary but is generally an even number that is 6or greater (6 and 8 being the preferred values), though otherconfigurations are possible.

For simplicity, the optional leader 120 shown, for example, in FIG. 1,is depicted schematically as leader 1805 in FIG. 18 and FIG. 19. Thepreferred embodiment includes a short twist to end portion 1805 (notshown for clarity) which may be one or more twists in length. In generalfor many applications it is desirable to have leader 1805 be less thanthree twists, and most preferably a single twist or a portion of acomplete twist. Leader 1805 joins aperture portion 115 at a pair ofbends. Body portion 110 (not shown in FIG. 18 and FIG. 19) also joinsaperture portion 115 at a second pair of bends.

The configuration of the angles as described by this embodiment withhard angles joined at the twists improves the opening and closing ofaperture portion 115 to increase reliability and improve the size of theenclosed area of the loop. It, along with use of non-shearingcross-sectional profiles of the filaments, also enables the expansionand contraction of aperture portion 115 to be implemented by ascissoring action to form a scissor trap.

During some operations, a very large pull force is applied to transport100 and it is desirable to trap reliably a suture within apertureportion 115. The hard angles, particularly those proximate leaderportion 1805, assist in retaining the suture within aperture portion 115while pulling, particularly while applying relatively large pull forcesthat may exceed a hundred foot-pounds. Additionally, in some instances,it is possible for an operator to purposely use the scissor trap bypassing a suture through aperture portion 115 and then retracting bodyportion 110 into a channel (e.g., the channel of the percutaneousdelivery system) to begin to collapse aperture portion 110 onto thesuture using the scissoring action implemented by the bends and theirrelative configuration to other elements. This scissor trap makes itpossible to very securely grip the suture and enabling relatively largepull forces that may equal or exceed 500 foot-pounds of pulling force.Maintaining the engagement of the scissor trap is achieved by therelative location of the transport within the channel. In someinstances, leader portion 1805 may have a different configuration toimprove trapping for pulling.

In many instances, particularly for configurations supporting largepulling forces (but not exclusively for this purpose), it is preferredthat aperture portion 115 be of a single monofilament of shape memorymaterial sized to fit a twisted strand within the channel; in contrastto a twisted braided multi-filament. One potential drawback of braidedmulti-filament used in aperture portion 115 is that it is very difficultto exactly match lengths properly resulting in uneven load distributionsthat may cause cascading failures of the individual filaments, thuscausing the entire aperture portion 115 to fail.

In some embodiments, it may be desirable to insert an inner moveablesheath or channel into the percutaneous delivery system. In suchinstances, transport 100 is sized for the inner dimensions of thissheath.

The percutaneous delivery subsystem is a skin-piercing/puncturing systemdifferent from systems and methods that make an incision to form all orpart of the portal or opening, including those that insert cannulas, andmost preferably provide a pair of openings—one exterior to the body andone interior proximate a desired delivery point. Thesenon-piercing/non-puncturing systems are more traumatic to the tissuethan insertion of a small gauge (e.g., 18 gauge or smaller diameter).The fine gauge permits precise and simple placement of a suture atvirtually any location. When desired, the percutaneous deliverysubsystem and transport may be used for multistage suture pathdefinition or discrete definition of suture path segments, at the optionof the operator in any specific case. Thus the embodiments are simpleand efficient, applicable to many situations and implementations.

In the description herein, numerous specific details are provided, suchas examples of components and/or methods, to provide a thoroughunderstanding of embodiments of the present invention. One skilled inthe relevant art will recognize, however, that an embodiment of theinvention can be practiced without one or more of the specific details,or with other apparatus, systems, assemblies, methods, components,materials, parts, and/or the like. In other instances, well-knownstructures, materials, or operations are not specifically shown ordescribed in detail to avoid obscuring aspects of embodiments of thepresent invention.

Reference throughout this specification to “one embodiment”, “anembodiment”, or “a specific embodiment” means that a particular feature,structure, or characteristic described in connection with the embodimentis included in at least one embodiment of the present invention and notnecessarily in all embodiments. Thus, respective appearances of thephrases “in one embodiment”, “in an embodiment”, or “in a specificembodiment” in various places throughout this specification are notnecessarily referring to the same embodiment. Furthermore, theparticular features, structures, or characteristics of any specificembodiment of the present invention may be combined in any suitablemanner with one or more other embodiments. It is to be understood thatother variations and modifications of the embodiments of the presentinvention described and illustrated herein are possible in light of theteachings herein and are to be considered as part of the spirit andscope of the present invention.

Additionally, any signal arrows in the drawings/Figures should beconsidered only as exemplary, and not limiting, unless otherwisespecifically noted. Furthermore, the term “or” as used herein isgenerally intended to mean “and/or” unless otherwise indicated.Combinations of components or steps will also be considered as beingnoted, where terminology is foreseen as rendering the ability toseparate or combine is unclear.

As used in the description herein and throughout the claims that follow,“a”, “an”, and “the” includes plural references unless the contextclearly dictates otherwise. Also, as used in the description herein andthroughout the claims that follow, the meaning of “in” includes “in” and“on” unless the context clearly dictates otherwise.

The foregoing description of illustrated embodiments of the presentinvention, including what is described in the Abstract, is not intendedto be exhaustive or to limit the invention to the precise formsdisclosed herein. While specific embodiments of, and examples for, theinvention are described herein for illustrative purposes only, variousequivalent modifications are possible within the spirit and scope of thepresent invention, as those skilled in the relevant art will recognizeand appreciate. As indicated, these modifications may be made to thepresent invention in light of the foregoing description of illustratedembodiments of the present invention and are to be included within thespirit and scope of the present invention.

Thus, while the present invention has been described herein withreference to particular embodiments thereof, a latitude of modification,various changes and substitutions are intended in the foregoingdisclosures, and it will be appreciated that in some instances somefeatures of embodiments of the invention will be employed without acorresponding use of other features without departing from the scope andspirit of the invention as set forth. Therefore, many modifications maybe made to adapt a particular situation or material to the essentialscope and spirit of the present invention. It is intended that theinvention not be limited to the particular terms used in followingclaims and/or to the particular embodiment disclosed as the best modecontemplated for carrying out this invention, but that the inventionwill include any and all embodiments and equivalents falling within thescope of the appended claims. Thus, the scope of the invention is to bedetermined solely by the appended claims.

What is claimed as new and desired to be protected by Letters Patent ofthe United States is:
 1. A method for repairing a superior labrumanterior to posterior (SLAP) tear employing a posterior portal and ananterior portal without a lateral portal, the posterior portal forviewing using a scope and the anterior portal for working usingarthoscopic tools, the method comprising: a) installing the posteriorportal and the anterior portal into a shoulder proximate the superiorlabrum; b) installing a suture anchor at about a forty-five degree angleinto a glenohumeral joint of said shoulder, said suture anchor includinga plurality of sutures; c) piercing a portion of skin of said shoulderwith a needle at a particular location outside said shoulder andpiercingly inserting percutaneously said needle into said shoulder alonga piercing path from said particular location to another location insidesaid shoulder with a sharp distal end of said needle adjacent said otherlocation, wherein said needle extends from a first opening at saidparticular location to a second opening at said another location alongsaid piercing path without extending through any portal and wherein saidneedle includes an internal channel extending from said first openingoutside said shoulder to said second opening at said sharp distal end;d) introducing a suture transport into said glenohumeral joint throughsaid internal channel of said needle by inserting said suture transportinto said first opening and exiting said suture transport from saidsecond opening, said suture transport formed by a pair of shape memoryalloy elements wound about each other forming a body and an apertureportion and said aperture portion including an aperture between saidelements, said aperture is collapsed when inserted into said firstopening and said aperture automatically expanded when exiting saidsecond opening; e) coupling a different one of said plurality of suturesto said aperture of said suture transport; and f) extracting said suturetransport from said shoulder at said particular location along saidpiercing path while said different one suture is coupled to saidaperture, to extend said different one suture from said anchor outsidesaid shoulder at said particular location; wherein steps c)-f) arerepeated for each said different one suture of said plurality of suturesand said particular locations for each said different one suture aredifferent locations from any other particular location; wherein at leastone said piercing path passes through a supraspinatus tendon; andwherein at least one suture of said plurality of sutures extends throughsaid supraspinatus tendon after an extracting step f) including said atleast one piercing path extending through said supraspinatus tendon. 2.The method of claim 1 wherein said needle is no greater than an 18 gaugeneedle and wherein said internal channel has an internal channel widthno greater than a nominal inner diameter of said 18 gauge needle.
 3. Themethod of claim 2 wherein said suture extends outside said shoulderthrough the anterior portal, and wherein each said coupling step e)includes exiting said aperture outside said shoulder through theanterior portal while said body extends from said particular location tosaid aperture portion, said coupling step e) engaging said different onesuture with said suture transport outside said shoulder while saidaperture extends outside said shoulder.
 4. The method of claim 3 furthercomprising for each different one suture: g) withdrawing said needlefrom said shoulder while said body is disposed within said shoulder andsaid aperture extends outside said shoulder through the anterior portal,said body extending from said particular location to said apertureportion wherein said withdrawing step g) does not remove said body fromwithin said shoulder; and thereafter; h) pulling on said body while saidsuture is engaged with said aperture wherein said pulling step h)withdraws said body including both said aperture and said suture fromsaid shoulder at said particular location.
 5. The method of claim 1wherein said suture extends outside said shoulder through the anteriorportal, and wherein each said coupling step e) includes exiting saidaperture portion outside said shoulder through said anterior portalwhile said body extends from said particular location to said apertureportion, said coupling step e) engaging said different one suture withsaid suture transport outside said shoulder while said aperture extendsoutside said shoulder.
 6. The method of claim 5 further comprising foreach said different one suture: g) withdrawing said needle from saidshoulder while said body is disposed within said shoulder and saidaperture extends outside said shoulder through the anterior portal, saidbody extending from said particular location to said aperture portionwherein said withdrawing step g) does not remove said body from withinsaid shoulder; and thereafter; h) pulling on said body while said sutureis engaged with said aperture wherein said pulling step h) withdrawssaid body including both said aperture and said suture from saidshoulder at said particular location.
 7. The method of claim 1 whereinsaid needle is an 18 gauge or smaller needle.